Functional Medicine New Patient Application

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Tamsyn Shelton
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Functional Medicine New Patient Application PLEASE ANSWER ALL QUESTIONS. IF THE QUESTION DOES NOT APPLY TO YOUR SITUATION PLEASE PUT N/A NEXT TO THE QUESTION.

1 Functional Medicine New Patient Application PLEASE ANSWER ALL QUESTIONS. IF THE QUESTION DOES NOT APPLY TO YOUR SITUATION PLEASE PUT N/A NEXT TO THE QUESTION. Name Age Sex: M F DOB Date Address City State Zip Home Phone Work Phone Cell Phone May we leave a voice mail on your phone? Y N Height Weight SSN: How did you hear about us? Employer Occupation Length of Employment Present Complaints 1. Main Problem(s): 2. In spite of the fact that you are not a doctor, you are in fact the person who knows more about your condition than anyone else. In your own words and your own opinion what do you think the real cause may be?: 3. When were you diagnosed with your present condition(s)?: 4. What diagnostic tools were used to achieve your diagnosis (ex: blood tests, X-Rays, MRI etc.)?: 5. What are the 3 things your condition has caused you to miss most in your life?

2 6. Symptoms (please list all): 7. Severity of problem (circle one): Minimal (annoying but causing no limitation) Slight (tolerable but causing a little limitation) Moderate (sometime tolerable but definitely causing limitation) Severe (causing significant limitation) Extreme (causing near constant limitation (>80% of the time) 8. What aggravates your symptoms or causes them to return? 9. Describe the first time you remember having symptoms: 10. If your symptoms include pain: What is the quality (sharp, dull, stabbing, color, etc) Does the pain radiate? Y N Where: 11. Do your symptoms occur at a specific time, place, or environment? Yes No When and for how long do symptoms last each episode?: 12. What types of treatment have you received? Prescription/ Drug Therapy Nutritional Alternative/Holistic 13. List all your health goals in order of Importance: 14. Motivation to achieve these goals: SCALE: ( 1: not motivated : very motivated ) Please circle a number:

3 15. What are you hoping happens today as a result of your consultation? 16. How often are you aware of your main problem?(circle one): Occasionally (25% of the time) Frequently (75% of the time) Intermittently (50% of the time) Constantly (100% of the time) 17. If you cannot find a solution to your problem what do you think will happen? 18. Due to your condition have you lost time from (describe how much time and what tasks have been limited)? Work: Family Leisure Y N Describe: Y N Describe: Y N Describe: 19. Medication: (List all prescriptions and over-the-counter medications) Please list past or present allergies, including allergies to medications. 20. Nutritional Supplements: (List all botanicals, herbs, homeopathic, and supplements) 21. What is your employment history? Please provide brief summary including dates if possible. 22. Please list your past or present Hobbies that could be sources of toxicity or chemicals:

4 23. How often are you involved in these Hobbies currently? 24. Medical and Social History: Surgeries and Hospitalizations Date(s) Trauma Date(s) Past and Recent Illnesses Date(s) 25. Marital Status: Single Married Widowed Separated Divorced Spouse: Children/ Ages: Living with: Spouse Partner Parents Children Friends Alone 26. Family Health History: (mother, father, siblings, spouse, children) 27. Do you use: Alcohol: Y N drinks/week Tobacco: Y N pack/day Caffeine: Y N cups/day 28. Please list any other information you feel may be relevant to your situation or condition and would like to discuss with the doctor.

5 Patient History Answer the following questions to the best of your ability. If you don t know the answer, simply leave it blank. Mercury Yes No Do you have amalgam (silver) fillings in your teeth? If so, How many? Yes No Have you ever had an amalgam removed? If Yes, How many Date? Yes No If you had amalgams removed, was it done by a biological dentist using a safe protocol? Yes No Did your mother have amalgam when pregnant with you? Yes No Have you ever worked in a dental office? If so, how long? Yes No Have you had any dental crowns? If yes, how many Yes No Have you had any bridges? Yes No Have you had any root canals? Yes No Have you had any tooth extractions? Yes No Do you have any dental implants, retainers or other metal in your mouth? Explain: Yes No Did you wear contact lenses during the 1980 s or early 1990 s? Yes No Did you take oral contraceptives during the 1980 s or early 1990 s? Yes No Did you receive yearly flu shots or have you recently received a flu shot, allergy shot or a vaccination? Yes No Have you noticed any adverse reactions to these shots? Yes No Do you have any tattoos with red ink? Yes No Do you eat large amounts (more than twice a week) of tuna, shark, swordfish or Atlantic Salmon? Lead Yes No Does your occupation involve soldering or metal salvage? Yes No Have you done any old home repair or sandblasting? If so, When Yes No Do you do a lot of painting?

6 Yes No Was your home built before 1978? Yes No Have you ever worn cosmetics containing kohl? (make-up with dark black or deep red pigment) Yes No Are you around a lot of fake leather, or vinyl? Yes No Do you get stomach aches in the morning? General Toxicity Yes No Have you ever lived near, on or by a golf course, freeway or tension wires? If yes, please explain. Yes No Have you ever had any chemical exposures? (i.e. cleaning chemical spills, working in a beauty salon, etc.) Yes No Do you have your house sprayed with pesticides for pest control? Yes No Do you spray herbicide (weed killers) in or around your home? Yes No Do you use conventional insect repellants on your self or family? Yes No Do you use conventional sunscreen? Yes No Do you use conventional perfume or cologne every day? Yes No Do you get your hair colored? If so, is it on the scalp? Yes No Do you use aerosol hairspray? Yes No Do you get your nails done? If so, how often? Yes No Do you use air freshener in your house, work or car? Yes No Do you drink filtered water? If so, what type of filter do you have? Yes No Do you drink bottle water if so what kind? Yes No Do you have a water filtration system for your entire house or shower filtration? If so, what type? Yes No Does your spouse or other family members work around chemicals? Yes No Can you think of any other toxic exposures you may have had?

7 Mold How old is the house you are living in? How long have you lived there? Have you noticed any new symptoms since moving in? If so, what? Yes No Do you see mold growing at home, work or school? Yes No Have you ever had water damage at home, work or school? Yes No Does your home, workplace or school have a damp or mildew smell? Yes No Does spending time in your basement cause or worsen your symptoms? Yes No Does your basement ever get wet? Yes No Do you have a crawl space? Yes No Does your basement or crawl space have a sump pump? Yes No Does spending time in a different location for at least a few days cause a noticeable decrease in your symptoms? Yes No Does your car have a mildew smell? Yes No Does anyone in your home have asthma like symptoms? Yes No Does anyone in your family have chronic sinus infections or irritations? Lyme Disease Yes No Have you ever been diagnosed with Lyme Disease? Yes No Have you had dry sockets or infected tooth extractions? Yes No Do you have small joint pain? Yes No Have you ever been bitten by a tick or recluse spider? Yes No Have you ever seen a bulls-eye rash appear on any part of your body? Yes No Did the bulls-eye rash appear shortly after following a tick, spider bite or time spent outdoors? Yes No Was your mother ever diagnosed with Lyme Disease? Yes No Have you ever been diagnosed with Chronic Fatigues Syndrome, Fibromyalgia, Lupus, Rheumatoid Arthritis (RA), Multiple Sclerosis (MS), or an Autoimmune condition? Yes No Do you frequently go camping, hunting or are you involved in outdoor activities (specifically in wooded or grassy areas)?

8 Health History Yes No Have any members of your family been diagnosed with fibromyalgia, chronic fatigue or multiple chemical sensitivities? Yes No Does anyone in your family experience similar symptoms to yours? What is your birth order (i.e. first born, second, third, etc.)?. Yes No Do you have any history of kidney dysfunction? Yes No Do you or any immediate family member have a history with cancer? Yes No Do you have any history of heart disease, myocardial infarction (heart attack), etc.? Yes No Are you currently having any thoughts of suicide? Yes No Have you ever been diagnosed with bipolar disorder, schizophrenia or depression? Yes No Do you have a history of strokes? Yes No Have you ever been diagnosed with diabetes, thyroiditis, or heart disease? Yes No Have you ever been in an auto accident, fallen or received a major physical injury? Yes No Are you in menopause? Microbiome Health Yes No Do you get distention, bloating, feeling full and a noisy gut after eating healthy carbohydrates such as broccoli, Brussels sprouts or other vegetables? Yes No Do you often have gas that has a sulfur or foul smell? Yes No Are you sensitive to supplements? Yes No Have you ever been vegan or vegetarian for any length of time? Yes No Can you tolerate Meat? Yes No Do you have a history of using anti-acids, proton pump inhibitors or anything else that blocks acid? Yes No Have you taken birth control or Hormone replacement therapy for any length of time? Yes No If/When you consume alcohol, do you get brain fog or a toxic feeling even after 1 serving? Yes No Have been on antibiotics for any extended period of time or often as a child or adult? Yes No Were you caesarian delivered?

9 Yes No Were you breast fed? If so, How long Yes No Does your gut temporarily feel better after a round of antibiotics? How many times a day are you having a bowel movement? Rate each of the following symptoms to the best of your ability based upon your typical health profile over the last year. If you cannot answer a question, simply leave it blank. Point Scale 0 = Never had the symptom 2 = Occasionally have it, severe effect 4 = Frequently have it, severe effect 1 = Occasionally have it, mild effect 3 = Frequently have it, mild effect Column #1 Column #2 Anxiety Sensitivity to light Mood swings Fatigue after exercising (feeling worse) Enraged behavior or anger for no reason Bad night vision or seeing halos around lights Excessive shyness, timidity, social phobia (not typical to your personality) Shortness of breath, with very little effort Irritability (not typical to your personality) Excessive thirst and/or frequent urination Low body temperature (below 97.5 o ) Red eyes or tearing Insomnia (can t get to sleep or return to sleep Blurred vision at times Dizziness Morning stiffness Sound in ears (ringing or hearing your heart beat) Sensitivity to smells, including chemicals such as petrochemicals, perfumes, air fresheners Psychological symptoms, even thoughts of suicide Chronic fatigue or weakness Sensitivity to sound Non-restful sleep Indecisiveness Receive static shock more often and w/more dramatic effect than normal (doorknobs, car, light switch, people, etc.)

10 Feeling of being overwhelmed or fearful Trouble processing new information Metallic taste in your mouth Word reversal or trouble finding words Bad breath Sensitivity to touch Bleeding gums Short-term memory loss Sensitive teeth Chronic sinus congestion Canker sores or other sores in the mouth Dry non-productive cough Floaters, shadows or swimmers when you read or look into the sky Muscle twitching Dyslexia or loss of place while reading, even as a child Excessive sweating, especially at night Swelling eyelids Joint pain-not necessarily true arthritis-can move from joint to joint Peeling on top layer of skin (hands, feet) Difficulty losing weight regardless of diet or exercise Dry skin Persistent fungal or viral infection, including athletes foot, warts, jock itch, candidiasis Heart pain (angina) and you are under 45 years old Frequent illness, prolonged illness or sick days Depression Numbness or weakness in arms and legs Gout (arthritic pain, especially in big toes) Headaches Pain in shoulders or upper back Trouble adding or dividing numbers in your head Twitching eyelids Fluctuating constipation and diarrhea Anemia (low iron/hemoglobin on blood test) Stomach pain for no apparent reason Wrist/ankle drop or weak extensor muscles Appetite swings Hair falls out (not normal male pattern baldness) Frequent muscle aches, cramps, unusual sharp sudden pains Rashes or rosacea Cold extremities (hands and feet) Total Columns 1 & 2 Revelation Health 2013; All Rights Reserved

Health History & Neurotoxic Questionnaire

Dr. Barbara L. Jennings, DC Health History & Neurotoxic Questionnaire Date: Name: Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: E-mail Address: Age: Date of Birth: Gender: Male Female